Luther and Lutheranism

Martin Luther was eight years old when Christopher Columbus set sail from Europe and landed in the Western Hemisphere. Luther was a young monk and priest when Michaelangelo was painting the Sistine Chapel in Rome...

ELCA Good Gifts Catalog

Assignment Process

Assignment completes candidacy for all people, including those ordained in another Lutheran church or Christian tradition, moving them toward first call and admittance to the appropriate roster in the ELCA...

Joint Observance

The ELCA Conference of Bishops' Ecumenical and Inter-Religious Liaison Committee and the United States Conference of Catholic Bishops' Ecumenical and Interreligious Affairs Committee commemorate the 500th anniversary of the Reformation by signing a joint statement during a Lutheran-Catholic service of Common Prayer.

Reformation 500

Martin Luther posted his “Ninety-Five Theses” in Wittenberg on Oct. 31, 1517, and the resulting debate about Christian teaching and practice led to changes that have shaped the course of Western Christianity for almost 500 years.

Let God be the Judge: Who Will Throw the First Stone?

[1] In Dietrich Bonhoeffer's Ethics he alerts us to the
pitfalls of the quest for moral certainty and to the shortcomings
of one-principle or one-theme ethical approaches.

[2] The typical ethical approach focuses on two primary tasks:
one, identifying a fundamental moral principle; and two, applying
this fundamental principle to specific ethical issues to determine
good and evil, right and wrong, or moral and immoral. According to
Bonhoeffer "the first task of Christian ethics is to invalidate
this knowledge."[1] Seeking to secure our
knowledge of good and evil separates us from God.

[3] The quest for moral certainty and one-principle or one-theme
ethical approaches become particularly problematic in addressing
what Bonhoeffer calls an "extraordinary situation of ultimate
necessities." Responsible action in an extraordinary situation of
ultimate necessities "leaves behind it the domain of principle and
convention, the domain of the normal and the
regular.[2] " No law can control such
a situation. Bonhoeffer's own involvement in the conspiracy against
Hitler was an example of an extraordinary situation of ultimate
necessity. Bonhoeffer was compelled to act as he did, but he
intentionally sought to avoid justifying his actions, before,
during, or after what he did. The ultimate judgment upon his
actions had to be left in God's hands.[3]

[4] The purpose of this paper is to show how Bonhoeffer's
concept of an extraordinary situation of ultimate necessities sheds
light on the issue of physician-assisted suicide, in particular as
we are struggling with it in the state of Oregon. In November
of 1994 the citizens of Oregon narrowly approved Ballot Measure
#16, the "Death with
Dignity Act," or as it was more commonly known, the
"Physician-Assisted Suicide Act." This measure made it legal,
within certain established guidelines, for physicians to prescribe
medication to terminally ill Oregon residents to end their lives.
In 1995 a federal judge in Eugene, Oregon, ruled that the Death
with Dignity Act did not adequately protect the terminally ill and
therefore it was unconstitutional. Thus it did not actually take
effect until the 9th U.S. Circuit Court of Appeals reversed this
ruling on October 27, 1997. In November 1997 Measure 51, which
would have repealed the Death with Dignity Act, was defeated by
Oregon voters by a 3 to 2 margin. On October 27, 1999 the U.S.
House passed the
Pain Relief Promotion Act by a vote of 271-156. This law
specifies that it is illegal to prescribe controlled substances for
assisted suicide. It has been approved in the Senate Judiciary
Committee but has not yet been sent to the floor. Senator Ron Wyden
of Oregon, who personally opposes physician-assisted suicide, has
defended the right of the people of the State of Oregon to make
their own law on this issue. He has threatened to filibuster if the
Pain Relief Promotion Act is brought to the floor of the Senate. It
appears now, however, that Wyden and Senator Don Nickles of
Oklahoma, the Senate Sponsor of this act, have reached an agreement
that would allow it to be brought before the Senate for
consideration in September. Passage of the Pain Relief Act seems
likely, but at this time physician-assisted suicide remains a legal
option in
Oregon.

[5] The Evangelical Lutheran Church in America (ELCA) of which I
am a pastor has taken a definite stand against physician-assisted
suicide. A November 1992 "End-of-Life Decisions" message by the
ELCA Church Council states: "We oppose the legalization of
physician-assisted death[4], which
would allow the private killing of one person by
another."[5] The primary reason given
for opposing physician-assisted death is that "deliberately
destroying life created in the image of God is contrary to our
Christian conscience."

[6] While I affirm a strong Christian presumption to preserve
and protect life created in the image of God, I don't believe that
necessarily entails an absolute prohibition on physician-assisted
suicide. Recognizing that life is a precious gift from God,
Christians do not want to encourage anyone to take his or her own
life in any circumstances. Nevertheless, Christians need to
recognize that in the course of life there may arise an
"extraordinary situation of ultimate necessities" in which someone
would choose physician-assisted suicide. Even the ELCA Message on
End-of-Life Decisions includes an acknowledgment that "responsible
health care professionals struggle to choose the lesser evil in
ambiguous borderline situations -- for example, when pain becomes
so unmanageable that life is indistinguishable from torture." In
such extraordinary or borderline situations the responsible action
is not to cast the first stone nor to affirm physician-assisted
suicide but to suspend judgment and let God be the judge.

Physician-Assisted Suicide in Oregon

[7] Ballot Measure 16, the "Death with Dignity Act," posed the
question to voters: "Shall law allow terminally ill adult Oregon
patients voluntary informed choice to obtain physician's
prescription for drugs to end life?" Mercy killing and lethal
injections by physicians were prohibited, but physicians were
permitted to prescribe medication and give necessary instructions
to qualified patients who desired to use the medication to commit
suicide.[6]

According to the Death with Dignity Act, in order to qualify
for medication to end their lives, patients must go through a
series of 9 steps:

1. The patient must be 18, terminally ill (having less than 6
months to live), and an Oregon resident.

2. The patient must voluntarily make an oral request to the
attending medical/osteopathic physician for a prescription for
medication to end his or her life. A 15-day waiting period then
begins.

3. The attending physician makes sure the patient understands the
diagnosis and prognosis. The patient is informed of all options,
including pain control, hospice care, and comfort care. The
attending physician also must inform the patient of the risks and
expected result of taking the medication.

4. The attending physician a) determines whether the patient is
capable of making health care decisions and is acting voluntarily;
b) encourages the patient to notify next of kin; c) informs the
patient that he or she can withdraw the request for medication at
any time and in any manner; and d) refers the patient to a
consulting physician who is asked to confirm the attending
physician's diagnosis and prognosis.

5. The consulting physician also decides whether the patient is
capable of making the decision and is acting voluntarily. If either
or both physicians believe the patient is suffering from a
psychiatric or psychological illness or depression that causes
impaired judgment, the patient will be referred for
counseling.

6. Once the preceding steps have been satisfied, the patient
voluntarily signs a written request witnessed by two people. At
least one witness cannot be a relative or an heir of the
patient.

7. The patient then makes a second oral request to the attending
physician for medication to end his/her life.

8. The attending physician again informs the patient that he or
she can withdraw the request for medication at any time and in any
manner.

9. No sooner than 15 days after the first oral request and 48
hours after the written request, the patient may receive a
prescription for medication to end his or her life. The attending
physician again verifies at this time that the patient is making an
informed decision.[7]

[8] In February 1999 the Oregon Health Division issued a report
on the first year of physician-assisted suicide in the state.
Twenty-three patients received lethal prescriptions. Fifteen used
the prescription to die; 6 died from their terminal disease; and 2
remained alive as of January 1, 1999. According to their doctors,
the 15 who died specified the following end-of-life concerns: 12
loss of autonomy due to illness; 10 inability to participate in
activities; 8 loss of control of bodily functions; 2 burden on
family, friends, or other caregivers; 1 inadequate pain control. No
one specified the cost of treating illness or prolonging
life.[8]

[9] Kathleen Foley and Herbert Hendin issued a scathing response
to the Oregon Health Division's report on the first year of
physician-assisted suicide. They believe the Oregon report does not
provide sufficient data to support its conclusion that "patients
who were assisted in suicide were receiving adequate end of life
care."[9] They are especially
critical of the lack of information on the palliative care offered
to patients requesting physician-assisted suicide and on their
financial situation and emotional state. They maintain that the
Oregon Health Division ought to have asked physicians to provide
more medical information about their patients. From their point of
view, "the presumption that a diagnosis of terminal illness is
sufficient for assisted suicide does not encourage physicians to
inquire into the source of the medical, psychological, social, and
existential concerns that usually underlie such
arequest."[10] They propose that in
addition to asking for more information from the physicians the
Oregon Health Division should "appoint a task force made up of
physicians from out of the state who are experts in palliative
care, psychiatry, and medicine to review the assisted suicide
cases."[11] Furthermore, given that
psychiatric evaluation is standard medical practice for patients
who are suicidal, they assert that the Oregon law ought to require
that the "physician refer the patient to a licensed psychiatrist or
psychologist for counseling."[12] They
are also concerned about the lack of an adequate mechanism for
resolving disagreement in a particular case - for example, a
mechanism such as an ethics consultation committee.

[10] In response to Foley and Hendin representatives of the
Oregon Health Division claim the law does not authorize them to
gather the information that Foley and Hendin seek. The Oregon
Health Division maintains they are trying to operate within the
parameters of the legal mandate given to them. However, in
anticipation of criticisms of their year two report, they
interviewed family members of 19 of the 27 physician-assisted
suicide cases in 1999, something they did not do for 1998
cases.[13] Whether or not the
monitoring process by the Oregon Health Division is flawed as Foley
and Hendin suggest, their proposals for ensuring medical personnel
are adequately trained in end-of-life care, for requiring
psychiatric evaluation, and for encouraging ethical consultation
would strengthen the safeguards and the guidelines for the Death
with Dignity Act.

[11] I share the concern of Foley, Hendin, that the guidelines
governing physician-assisted suicide be strengthened. At the same
time I am concerned about those who would want to build a
categorical prohibition of physician-assisted suicide into the law
of the land. The Pain Relief Act if passed into law will
effectively make physician-assisted suicide illegal in Oregon. In
the long run that could easily strengthen the resolve of the
majority who support giving dying patients the option of
physician-assisted suicide. It could set up a seemingly never
ending legal battle similar to what we have experienced with the
issue of abortion.

[12] At least in Oregon, where the voters have spoken once and
even more clearly a second time in favor of physician-assisted
suicide, trying to overturn the law may not be the most
constructive strategy. I am particularly concerned about the
strategy the church needs to pursue in a context in which
physician-assisted suicide is a legal option. Where it is a legal
option, the worst excesses of physician-assisted suicide can be
mitigated against, if it does not ever come to be viewed as
standard medical practice and is considered an option of last
resort in exceptional cases. Utilizing Bonhoeffer's concept of an
extraordinary situation of responsibility can be helpful in this
respect. If making a decision concerning physician-assisted suicide
is considered an extraordinary situation of responsibility, it may
be possible to keep cases of physician-assisted suicide from being
precedent setting for subsequent cases.

Responsible Action within the Domain of
Relativity

[13] Bonhoeffer identifies two basic factors that shape the
structure of the responsible life. The first is that the
responsible person is bound to God and to other human
beings.[14] The second is that the
responsible person is able to respond freely to God and to other
human beings. Responsible action is action on behalf of or in the
place of another. For example, responsible parents act on behalf of
or in the place of their children; a responsible police officer
acts on behalf of or in the place of the citizens of the community;
responsible teachers act on behalf of or in the place of their
students. Bonhoeffer views Jesus Christ as the responsible person
par excellence.[15] Jesus
gave himself completely on behalf of and in the place of others. He
performs the ultimate responsible action by taking upon himself the
guilt of all human beings and dying on the cross.

[14] Responsible action in ordinary situations focuses on
fulfilling the four mandates: labor, marriage, government, and
church. Bonhoeffer defines a mandate as a divinely imposed
task.[16] Through labor we
participate in the action of creation. Through marriage we share in
the process of creation by bringing children into the world and
nurturing them. Government is not creative but seeks to preserve
that which has been created. The primary task of the church is to
bear witness to the reality of God in Jesus Christ.

[15] These mandates are intended to work together to accomplish
God's purposes. There is no exact formula for balancing them. But
God does not want us to wear out in a constant conflict of
obligations and decisions. Each moment of life is not meant to be a
great crisis. In more ordinary times there is no need for us to be
"Hercules at the crossroads."[17] We
are free to fulfill the mandates without having to dissect every
action we engage in.

[16] On occasion in the course of life, however, we may find
ourselves in a moment of crisis. We may be called upon to engage in
an extraordinary venture of responsibility. It is difficult to
define what constitutes an extraordinary venture of responsibility,
because of its exceptional character. Nonetheless, utilizing
insights from Bonhoeffer, we can develop a matrix of
characteristics of an extraordinary venture of
responsibility. One, the focus is on God and others and not on
ourselves. According to Bonhoeffer "responsibility and freedom are
corresponding concepts." Responsible persons act in the freedom of
their own selves, but that very freedom is given "in the obligation
to God and to our neighbor."[18]

[17] Two, there is no clear theological or biblical or ecclesial
precedent that warrants the action being taken.

[18] Three, the action cannot be justified by any law. In fact,
the action may require a direct violation of the
law.[19]

[19] Four, in deciding to engage in the venture of
responsibility the full range of ethical factors is taken into
account. The responsible person will give due consideration to the
given circumstances, the relevant questions of principle, the
possible consequences, the motives, the values, and the purpose of
an action. No one factor ought to be made the governing principle
or law of the action.[20]

[20] Five, the action may oppose ordinary responsibilities-that
is, the mandates God calls us to fulfill in ordinary
situations.[21]

[21] Six, other more ordinary options have been exhausted. An
extraordinary venture of responsibility is an option of last
resort.

[22] Seven, the ultimate judgment upon the action is entrusted
to God. No claim is made to an ultimate knowledge of good and evil
in the given situation. As Bonhoeffer explains, the responsible
action is "performed wholly within the domain of relativity, wholly
in the twilight which the historical situation spreads over good
and evil; it is performed in the midst of the innumerable
perspectives in which every given phenomenon appears. It has not to
decide simply between right and wrong and between good and evil,
but between right and right and between wrong and
wrong."[22] The responsible action
is performed without any claim to self-justification. For
Bonhoeffer the deep secret of history is that our responsible
actions are ultimately committed to God. Only God can be the final
judge of our actions in an extraordinary situation.

[23] This matrix of characteristics helps explain why
Bonhoeffer's involvement in the conspiracy against Hitler
constitutes an extraordinary venture of responsibility. First, if
Bonhoeffer were primarily concerned about his own well-being, it is
unlikely he would have gotten involved in an attempt to assassinate
Hitler. The safest path for him would have been to stay in the
United States in 1939, when he had the opportunity.

[24] Second, there was no precedent for a Lutheran pastor in
Germany to be engaged in an attempt to kill the head of state.
[23]

[25] Third, Bonhoeffer's involvement in the conspiracy clearly
lacked any justification according to the law. Bonhoeffer himself
was fully aware that he was actually breaking the law.

[26] Fourth, Bonhoeffer was working on his Ethics while he was
involved in the conspiracy. The content of Ethics is an indication
of the wide range of ethical factors that he was considering. This
wide range of factors mitigated against coming to too quick a
judgment for or against the actions of the conspirators.
Furthermore, it would be hard to identify any one factor that could
possibly be made the law governing the action of the conspirators.
It is easier to identify some principles that would have prevented
Bonhoeffer from engaging in the conspiracy, if he had made those
principles the governing law of his action. For example, if
Bonhoeffer had in principle refused to lieor
deceive,[24] or if he had in
principle refused to be an accomplice in killing another person, or
if he had in principle believed that a pastor should not be
involved in a political matter, or if he had in principle refused
to break the law, he would not have been able to be involved in the
conspiracy.

[27] Fifth, being a conspirator against Hitler cost Bonhoeffer
an opportunity to get married to Maria, made it impossible for him
to serve a parish, and prevented him from teaching in Germany or in
the United States. These are precisely the responsibilities he
would have been fulfilling in more ordinary times.

[28] Sixth, Bonhoeffer's involvement in the conspiracy came
after a long process of pursuing other avenues to work against
Hitler and Nazism.[25] Finally the time came
when he felt compelled to help put a "spoke in the wheel."
Bonhoeffer would have admitted that he and the other conspirators
may have waited too long to take this extreme
measure.[26]

[29] Seventh, the way Bonhoeffer conducted himself in prison and
during his execution are signs that he had indeed entrusted the
judgment upon his actions to God as the only one who could possibly
justify his action. But he also knew that he had no basis on which
to claim that justification. He recognized that he was up against
the limits of human knowledge. In "After Ten Years" he suggests
that the conspirators had no ground under their
feet.[27] The good or the evil of
their actions had to be left for God to judge, and they could not
claim to have had any special insight into God's ultimate judgment
of good and evil before, during, or after the conspiracy.

[30] Although it appears that Bonhoeffer's involvement in the
conspiracy against Hitler does constitute an extraordinary venture
of responsibility, that does not mean we can conclude such a
venture was justified. Instead, it means that we should refrain
from judgment upon their action. We have reached the limits of our
human knowledge. We are not in a position to cast the first stone,
nor are we in a position to affirm the ultimate goodness of their
action. We need to let God be the judge.

Bonhoeffer on Suicide

[31] Bonhoeffer shared a strong presumption to preserve and
protect life. He was appalled by the Nazi effort to exterminate the
Jews and by their various euthanasia programs. In terms of suicide
he asserts in Ethics that human beings must not lay hands on
themselves.[28] However, in certain
extraordinary cases he maintains that "the prohibition of
suicide can scarcely be made absolute to the exclusion of the
freedom of sacrificing one's life."[29]

[32] Unlike other creatures, states Bonhoeffer, human beings can
put themselves to death of their own free will.[30] Because they are free
to choose death, they can lay down their lives "for the sake of
some higher good."[31] Thus, for Bonhoeffer
the right to live is not an absolute right; and although Bonhoeffer
does not state it explicitly, we do not have an absolute obligation
to live. The right to live and the obligation to live are always
conditioned by freedom.

[33] Bonhoeffer cautions that this freedom to choose death can
easily be abused. Human beings can use suicide as a last ditch
effort to maintain control over our earthly destiny. Shame and
despair over lost honor, financial ruin, rejected love, the death
of a loved one, or serious personal lapses can lead to suicide.
Thus, explains Bonhoeffer, the primary motivation for suicide is to
rescue oneself from this shame and despair, "and the ultimate
ground for the action will therefore be lackof
faith."[32] To lay one's hands on
oneself for purely personal reasons is an extreme act of
self-justification. It is a desperate act to give life meaning by
one who has lost confidence in God's ability to give meaning to a
ruined life.

[34] To avoid abusing the freedom to choose death, any decision
to kill oneself must take into account our responsibility to God
and other human beings. As we discussed earlier, freedom is a
corresponding concept of responsible action. Freedom is given in
the responsibility to God and to other human beings. Thus, we
remain accountable to God for what we do with our lives. God
maintains the right of life, even against those who have grown
weary of living.

[35] Bonhoeffer warns us, however, against categorically
condemning those who kill themselves for the sake of others. For
example, prisoners may kill themselves for fear that under torture
they might betray their country, their family, or their
friends.[33] When Bonhoeffer was
first imprisoned, he himself contemplated suicide for this very
reason. He was uncertain how he would hold up physically and
mentally under the strain of interrogation and torture. Once he
realized that he could mislead his interrogators and hold up under
the strain suicide receded as anoption.[34] Nonetheless, Bonhoeffer
understood from his personal experience why a political prisoner
facing torture would consider suicide for the sake of others.

[36] Bonhoeffer also envisions a case in which someone suffering
from a terminal disease might consider suicide. He writes: "If a
sufferer from incurable disease cannot fail to see that his care
must bring about the material and psychological ruin of his family,
and if he therefore by his own decision frees them from this
burden, then no doubt there are many objections to such an
unauthorized action, and yet here, too, a condemnation will be
impossible."[35]

[37] According to Bonhoeffer, when people take their own lives
for the sake of others, "we have reached the limits of human
knowledge."[36] If we have reached the
limits of human knowledge, we are dealing with an extraordinary
situation. We have no ground under our feet to make a definitive
judgment. In such extraordinary cases our response ought to be not
to cast the first stone but to suspend judgment. Suicide in an
extraordinary situation ought to be arraigned not before the forum
of human beings "but solely before the forum of God." Those who
take their own lives incur "guilt solely toward God, the Maker and
Master of their lives."[37]

Physician-Assisted Suicide: An Extraordinary
Decision

[38] The matrix of characteristics of an extraordinary venture
of responsibility as well as Bonhoeffer's specific insights on
suicide can assist the church in developing a strategy for
addressing physician-assisted suicide in a context such as Oregon
in which it is a legal option for the terminally ill. Limiting
physician-assisted suicide to extraordinary situations is an
attempt to keep cases of physician-assisted suicide from being
precedent setting for subsequent cases. The worst excesses of
physician-assisted suicide can be mitigated against, if it does not
ever come to be viewed as standard medical practice. At the same
time we need to avoid an absolute prohibition on physician-assisted
suicide. We need to acknowledge that there may arise an
extraordinary situation of ultimate necessities in which someone in
good faith would choose physician-assisted suicide. Utilizing the
seven characteristics of an extraordinary venture of
responsibility, what insights can we gain into physician-assisted
suicide?

[39] First of all, the patient is not an individual in
isolation. A decision to commit physician-assisted suicide ought
not be made simply by focusing on the condition of the patient. The
patient is a responsible person, a self in relationship. As the
ELCA "Message on End-of-Life Decisions" states, when Christians
make decisions as patients, they "should take into account and be
made in supportive consultation with family members, close friends,
pastor, and health care professionals. Christians face end-of-life
decisions in all their ambiguity, knowing we are responsible
ultimately to God, whose grace comforts, forgives, and frees us in
our dilemmas." Thus, a responsible decision will focus on God and
those around us and not merely on ourselves. Even those who do not
take account of God in their decision-making, which in Oregon is a
large percentage, still need acknowledge that they live in a
context of relationships. To ignore those relationships would be to
ignore the reality of our relational existence.

[40] Second, there is no obvious theological or biblical or
ecclesial precedent for physician-assisted suicide. The strong
Christian presumption is to preserve and protect life created in
the image of God. "You shall not kill" is, of course, one of the
Ten Commandments. Perhaps one could cite some precedent in
Bonhoeffer's notion of laying down one's life for the sake of some
higher good. But only in exceptional cases does one find a good
high enough to compel us to lay down our lives. The strong
resistance of much of the religious community to physician-assisted
suicide is an indication that in seeking physician-assisted suicide
a patient is venturing onto uncharted waters.

[41] Third, unlike Bonhoeffer's illegal involvement in the
conspiracy, physician-assisted suicide is a legal option in Oregon
for the terminally ill. Even if physician-assisted suicide is
legally permitted, however, that does not mean we are necessarily
justified in exercising that option. For people of faith the law of
the land does not dictate what is a responsible decision in an
extraordinary situation. If the Senate passes the Pain Relief
Promotion Act in September, terminally ill Oregonians will have no
legal ground under their feet for seeking physician-assisted
suicide. That will heighten the extraordinary character of
physician-assisted suicide.

[42] Fourth, the church needs to seek ways to ensure that the
full range of ethical factors is taken into account in decisions to
seek physician-assisted suicide. Patient autonomy has often
functioned as a kind of "boss principle" or trump card in medical
ethics. When the principle of patient autonomy conflicts with
others, it almost always seems to take precedence. As we have seen,
Bonhoeffer is highly critical of any ethical decision-making
process that gives one principle excessive sway. Patient autonomy
is a key factor, but motives, consequences, values, circumstances,
relationships, other principles, and any additional relevant
factors need to be given due consideration.

[43] One way to increase consideration of the full range of
ethical factors is to build a multi-disciplinary ethics
consultation into the process. In the Legacy Portland Hospitals
Ethics Program the consultation team is called upon approximately
3-5 times per month to assist patients, families, and/or health
professionals struggling to make difficult decisions. These are the
toughest cases. The purpose of this consultation team would not be
to serve as a gatekeeper but to ensure that all relevant ethical
factors in the case are being taken intoaccount.[38] If a multi-disciplinary
consultation were a required part of the physician-assisted suicide
decision-making process, the extraordinary character of such a
decision would be highlighted and greater responsibility could be
exercised in making such decisions. The Death with Dignity Act as
it currently stands places too great a burden on physician and
patient in the decision-making process. Every potential
physician-assisted suicide ought to be treated as a tough case; and
thus, consultation with a multi-disciplinary team ought not be
merely an option but a matter of course.

[44] Fifth, by the time one reaches the point of considering
physician-assisted suicide the terminally ill patient is not likely
in a position to fulfill the ordinary mandates or responsibilities
Bonhoeffer identifies. Often, however, terminally ill patients will
feel a sense of obligation to stay alive as long as possible for
the sake of the family and friends. In Bonhoeffer's example
of the terminally ill man who wants to prevent the material and
psychological ruin of his family physician-assisted suicide may be
a final extraordinary way for him to fulfill his responsibility for
his family. In such a case we ought to heed Bonhoeffer's caution
about condemning his action.

[45] Sixth, physician-assisted suicide needs to be an option of
last resort. Certainly no one can deny the strong Christian
presumption to preserve and protect life. Christians ought to be in
the forefront of efforts to reduce the desire of persons to turn to
physician-assisted suicide. Thus far in Oregon we have not had the
groundswell of requests for physician-assisted suicide that many
anticipated. Ironically, the Death with Dignity Act seems to have
been a catalyst in promoting a far more aggressive effort by health
care providers to improve comfort care and pain management, and
that effort would appear to be a factor in reducing the desire for
physician-assisted suicide. For example, the Legacy Health System
has launched a new Comfort Care Initiative. It began with a
systemwide daylong "Comfort Care Conference." The stated goal was
to "change the culture" of the entire Legacy System concerning
end-of-life care. One outgrowth of that conference was the
formation of a Comfort Care Consultation Team that is modeled after
Legacy Portland Hospital's Ethics Consultation Team. Despite the
improvements in comfort care and the relatively small number of
patients seeking physician-assisted suicide in 1998 and in 1999, it
is still vitally important to work against physician-assisted
suicide ever becoming a standard of care. If physician-assisted
suicide ever becomes a standard of care, we will have slid far down
the slippery slope.

[46] Finally, to advocate an absolute ethical injunction against
physician-assisted suicide is to overstep our bounds as human
beings. It is to ignore the limits of our human knowledge. We do
not need to be advocates for physician-assisted suicide, but we do
need to acknowledge that a situation may arise in which we will be
compelled to suspend judgment. In such situations we are making
decisions in the domain of relativity, and we need to entrust the
ultimate judgment to God. Some may not object absolutely to suicide
but still want to maintain an absolute injunction against the
participation of physicians in the act of suicide. But even this
absolute objection can be problematic. If Bonhoeffer had discerned
that he would fall apart under torture and would risk endangering
his family members and thus decided to commit suicide, and if one
of the guards who had befriended him had provided him with a
relatively painless means to do so, we would not be in a position
to cast a stone at the guard. The guard's assistance would not be
murder in any common sense of the term. Similarly a physician's
assistance in providing a relatively painless way for a terminally
ill patient to commit suicide does not fit our common understanding
of murder.

Conclusion

[47] The purpose of this paper has been to develop an approach
to physician-assisted suicide, utilizing Bonhoeffer's concept of an
extraordinary situation of responsibility, that keeps
physician-assisted suicide from becoming standard medical practice
and at the same time avoids an absolute prohibition of
physician-assisted suicide. Viewing each possible case of
physician-assisted suicide as an extraordinary decision is the key
step in fulfilling that purpose. In Oregon the Evangelical Lutheran
Church in America was at the forefront with several other mainline
churches in the effort to defeat the Death with Dignity Act. Having
failed twice, the second time miserably, the church needs to
redirect its efforts toward minimizing the need for
physician-assisted suicide. Rather than occupying the "proud throne
of the judge"[39] and casting stones, the
church needs to leave no stone unturned in supporting and
encouraging attempts to improve comfort care and pain management
and in advocating for increased consultation as a required part of
the process of seeking physician-assisted suicide. Improving
comfort care and pain management is an act of mercy. Building a
multi-disciplinary consultation team into the process will serve to
heighten the awareness of all involved of the extraordinary
character of any decision to end one's life. Such a decision, as
Bonhoeffer writes, cannot be arraigned before the forum of human
beings but ultimately must be arraigned before the forum of God. As
human beings we have an important role to play in the
decision-making process, but we need to let God be the judge.

[13]. A report on the second year was issued
in February 2000. In 1999 27 died by legal lethal prescription here
in Oregon. This year 19 of the 27 families of these patients were
interviewed about the reasons the patient sought physician-assisted
suicide. According to these families 10 patients feared losing
control of bodily functions; 10 feared loss of self-determination;
and 10 were afraid of physical suffering. 8 patients did not want
to become a burden to their families or caregivers, and 1 patient
was concerned about the cost of life-prolonging treatment
("Statistics Put Face on Assisted Suicide," The Oregonian
[Thursday, February 24, 2000]).

[37]. Mark D. Sullivan, Linda Ganzini, and
Stuart J. Youngner warn against casting psychiatrists as
gatekeepers in end-of-life decisions in "Should Psychiatrists Serve
as Gatekeepers for Physician-Assisted Suicide?" Hastings Center
Report 28, no. 4 (1998): 24-31. The Death with Dignity Act
instructs the attending physician to refer the patient for
psychological evaluation if the physician believes it is necessary.
This decision should not be left up to the physician. A
psychiatrist or psychologist ought to be one of the participants on
the ethics consultation team. Consultation needs to be
distinguished from a gate keeping function.

[38]. Mark D. Sullivan, Linda Ganzini, and
Stuart J. Youngner warn against casting psychiatrists as
gatekeepers in end-of-life decisions in "Should Psychiatrists Serve
as Gatekeepers for Physician-Assisted Suicide?" Hastings Center
Report 28, no. 4 (1998): 24-31. The Death with Dignity Act
instructs the attending physician to refer the patient for
psychological evaluation if the physician believes it is necessary.
This decision should not be left up to the physician. A
psychiatrist or psychologist ought to be one of the participants on
the ethics consultation team. Consultation needs to be
distinguished from a gate keeping function.

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